The present invention relates to compositions and methods for treating neoplasms in mammals, particularly humans. More particularly, combinations for intratumoral administrations of agents that coagulate tumors and agents that enhance the inflammatory response are provided. Also provided are methods for treating neoplasms by administration of the combinations.
A number of approaches, including surgery, chemotherapy and radiation, to cancer therapy have been used. Surgery is a traditional approach in which all or part of a tumor is removed from the body. Surgery generally is only effective for treating the earlier stages of cancer. For more than 50% of cancer patients by the time they are diagnosed, they are no longer candidates for effective surgical treatment. Surgical procedures may increase tumor metastases through blood circulation during surgery. Most of cancer patients do not die from the cancer at the time of diagnosis or surgery, but rather die from the metastasis and the recurrence of the cancer.
Other therapies are also often ineffective. Radiation therapy is only effective for local cancer therapy at early and middle stages of cancer, and is not effective for the late stages of cancer with metastasis. Chemotherapy can be effective, but there are severe side effects, e.g., vomiting, low white blood cells (WBC), loss of hair, loss of weight and other toxic effects. Because of the extremely toxic side effects, many cancer patients cannot successfully finish a complete chemotherapy regimen. Some cancer patients die from the chemotherapy due to poor tolerance to the chemotherapy. The extreme side effects of anticancer drugs are caused by the poor target specificity of such drugs. The drugs circulate through most normal organs of patients as well as intended target tumors. The poor target specificity that causes side effects also decreases the efficacy of chemotherapy because only a fraction of the drugs is correctly targeted. The efficacy of chemotherapy is further decreased by poor retention of the anti-cancer drugs within the target tumors.
Immunotherapy, including the use of cancer vaccines, such as autologous vaccines, is effective for cancer patients with tumor burdens of less than 108 tumor cells. Immunotherapy is often used as an adjunctive therapy in combination with other therapies such as surgery, radiation therapy and chemotherapy to clear out the remaining tumor cells. Immunotherapy and the use of tumor vaccines have not proven effective against a tumor burden greater than 5xc3x97109 to 1011 tumor cells, which is typical in a patient with small, symptomatic metastases. In addition, autologous tumor vaccination involves complicated procedures and requires a tumor specimen be processed for each patient to be treated.
Alcohol intratumoral injection therapy has been applied in clinical practices in the treatment of liver neoplasms and others cancers. Alcohol injection therapy alone does not kill all tumor cells because of the limiting volume of alcohol that can be injected, coagulating necrosis of normal living tissues caused by alcohol, alcohol dilution by the blood in the tumor to non-effective concentrations, especially when treating the large tumors and other factors. Alcohol cannot be injected close to critical structures, such as the central nervous system. Alcohol intratumoral injection therapy also has been administered with certain anti-tumor agents that are co-injected (Yu et al. (1994) J. Current Oncology, 1:97-100). In these protocols, the coagulated mass of tissue resulting from the alcohol injection serves as a slow release depot for the anti-tumor agent.
At present, there is no effective treatment for patients with high tumor burdens. Since early stage tumors are not easily detectable, many patients who are diagnosed with cancer are at the later stages of cancer with the tumor burden greater than 5xc3x97109 to 1011 tumor cells, or the tumor has already metastasized into other tissues. For these patients, traditional cancer therapies such as surgery, radiation therapy and chemotherapy may no longer be effective and/or suitable.
Despite some progress of cancer therapy, there are few, if any, effective treatments. Due to the severity and breadth of neoplasm, tumor and cancer, there is a great need for effective treatments of such diseases or disorders. An ideal cancer therapy should have the potency to eradicate systemic tumor at multiple sites in the body and the specificity to discriminate between neoplastic and non-neoplastic cells. Therefore, it is an object herein to provide treatments for such diseases and disorders. In particular, it is an object herein to provide a cancer therapy that has the potency to eradicate systemic tumor at multiple sites in the body and the specificity to discriminate between neoplastic and non-neoplastic cells.
Provided herein are combinations for intratumoral therapy that include agents that cause coagulation of tumor tissue and agents that enhance the inflammatory response to the resulting coagulated tissue mass. Preferred among the combinations are those that include three components (designated three in one or TIO) for intratumoral injection therapy and methods of treatment using the compositions. The combinations include an oxidizing agent or a reducing agent, a protein denaturing agent or other coagulating means or treatment, and a hapten. The combinations are used to treat tumors, e.g., solid tumors.
It is shown herein that these combinations, such as those that include one or more oxidizing agents and/or reducing agents, protein denaturing agents and haptens have broad applicability in the treatment of various types of neoplasms, tumors and cancers, particularly solid tumors that are not effectively treatable with traditional cancer therapy such as surgery, radiation therapy, chemotherapy and immunotherapy.
Provided herein are methods and compositions for treating neoplasms, tumors and cancers. Encompassed within the methods are the uses of any combinations of one or more oxidizing agents or reducing agents, protein denaturing agents and haptens that can alleviate, reduce, ameliorate, or prevent neoplasms, tumors and cancers; or place or maintain in a state of remission of clinical symptoms or diagnostic markers associated with such neoplasms, tumors and cancers, particularly solid tumors that are not effectively treatable with traditional cancer therapy such as surgery, radiation therapy, chemotherapy and immunotherapy. The combinations can be used alone or in conjunction with other treatments for neoplasms, tumors and cancers.
The neoplasms, tumors and cancers that can be treated include, but are not limited to, the neoplasm of adrenal gland, anus, auditory nerve, bile ducts, bladder, bone, brain, breast, bruccal, central nervous system, cervix, colon, ear, endometrium, esophagus, eye, eyelids, fallopian tube, gastrointestinal tract, head and neck, heart, kidney, larynx, liver, lung, mandible, mandibular condyle, maxilla, mouth, nasopharynx, nose, oral cavity, ovary, pancreas, parotid gland, penis, pinna, pituitary, prostate gland, rectum, retina, salivary glands, skin, small intestine, spinal cord, stomach, testes, thyroid, tonsil, urethra, uterus, vagina, vestibulocochlear nerve and vulva neoplasm. Preferably, the neoplasms, tumors and cancers to be treated is a solid tumor. The combinations are particularly effective for solid tumors, including solid tumor larger than 108 cells, e.g., from about 5xc3x97109 to about 1011 cells.
The combinations are provided to improve the therapeutic efficiencies of cancer therapy for most cancer patients, including very earlier stage cancer patients with visible tumor mass who may not be candidates for surgery and late stage cancer patients with larger tumors or metastases for whom the opportunity for surgery may have passed.
Each component may be a separate composition or agent or may be combined. The combination is intended to induce coagulation of the tumor and to enhance the inflammatory response to the coagulated tissue.
Hence, provided herein are combinations, preferably in the form of pharmaceutical compositions, including one or more oxidizing agents or reducing agents, protein denaturing agents and haptens. The combinations are typically pharmaceutical compositions that include an oxidizing agent or reducing agent, a protein denaturing agent and a hapten formulated for single dosage administration. The compound and agent can be administered separately, such as successively, or can be administered intermittently, or together as three separate compositions as a mixture in a single composition. When administered successively or intermittently, the time period between administration of each is typically on the order of less than a day, preferably less than an hour, but may be longer. The precise order and timing of administration can be determined empirically.
The dosage of each can be empirically determined, but is generally the dosage of an agent normally used to treat neoplasms, tumors and cancers, and an amount sufficient to further enhance other neoplasm treatment, or sufficient when used alone to reduce or ameliorate or in some manner reduce symptoms of the neoplasms. The combinations can be packaged as kits.
The compositions are administered directly into a tumor. Upon administration they result in coagulation of the tumor and create what is herein referred to as an intratumoral autologous drug release biomaterials depot. These biomaterials depots are called LAWBDs.
Immunologic adjuvants can also be administered with the combinations. Such adjuvants include, but are not limited to, Bacille Calmette-Guerin (BCG), interferons or the colony-stimulating factor GM-CSF after the pretreatment with low dose cyclophosphamide.
When the combination TIO is administered to form an LAWBD, the therapy immediately kills a lot of tumor cells by an over-dose oxidation (or reduction) of the tumor matrix and tumor tissue, which results in the shrinking of the tumor. This results in a lower tumor burden that is treatable with immunotherapy or treatment with tumor vaccines. It also creates an area of inflammation that attracts lymphocytes and other inflammatory response mediators to the target tumor site. The attracted lymphocytes include the tumor antigen presenting cells (APCs), macrophages, dendritic cells (DCs), and activated B cells. These lymphocytes are exposed to tumor antigens generated from the tumor cell lysis and elicit a tumor-specific immune response.
When the TIO makes an LAWBD with inflammation and tumor cell lyses, the lysed tumor cells in the resulting depot are modified with the haptens and generate modified, MHC-associated peptides with more complex immunogens, which are then released, and function as an autologous tumor vaccine. Such a tumor vaccine enhances the patient""s own tumor immunogenicity, stimulates T lymphocytes against the live tumor cells in and around the original tumor that are not killed by the initial coagulation, metastasized tumor and micro-lesions of tumor after the intratumoral coagulation therapy. This autologous tumor vaccination plays an important role for prevention of the tumor metastases and recovery from the original tumor.
In addition, additional therapeutic viruses or nucleic acids, e.g., DNA, cDNA, can also be included in the combination. Upon administration these will be encapsulated in the LAWBD and can be fused to or transfected into some of the remaining tumor cells in and around the LAWBD, producing in situ genetically modified tumor vaccines and hybrid vaccines. The tumor DNA or RNA from tumor lysis may be transfected into dendritic cells, which directly accept tumor antigen signals. The chemically and genetically modified intratumoral tumor vaccines cooperate to initiate effective antigen-specific and antigen-non-specific or co-stimulatory signal antitumor immunoresponses.
The combinations can also include other agents, such as anti-angiogenic agents, radiosensitizers and other cancer therapeutics. For example, upon administration of a TIO combination that additionally includes other such agents, the resulting coagulum (LAWBD) will slowly release anticancer drugs killing tumor cells not killed by the initial coagulation around original tumor site. The LAWBD can also slowly release radiosensitizer around tumor to increase the radiotherapy efficiency when it is needed. The LAWBD can further slowly release an anti-angiogenic agent to inhibit the blood microvessel formation for new tumor growth.
The anti-neoplastic (anti-cancer) agents used in the combinations and methods include, but are not limited to, an anti-angiogenic agent, an alkylating agent, an antimetabolite, a natural product, a platinum coordination complex, an anthracenedione, a substituted urea, a methylhydrazine derivative, an adrenocortical suppressant, a hormone and an antagonist, an oncogene inhibitor such as an anti-oncogene antibody or an anti-oncogene antisense oligonucleotide, an anti-cancer polysaccharide, or herb extracts such as Chinese herb extracts.
Anti-angiogenic agents include, but are not limited to, an inhibitor of basement membrane degradation, an inhibitor of cell migration, an inhibitor of endothelial cell proliferation, an inhibitor of three-dimensional organization and establishment of potency, an angiostatic gene, an angiostatic chemokine gene, AGM-1470 (TNP-470), angiostatic steroids, angiostatin, antibodies against avxcex23, antibodies against bFGF, antibodies against IL-1, antibodies against TNFxcex1, antibodies against VEGF, auranofin, azathioprine, BB-94, BB-2516, basic FGF-soluble receptor, carboxyamido-trizole (CAI), cartilage-derived inhibitor (CDI), chitin, chloroquine, cisplatin, CM 101, cortisone/heparin, cortisone/hyaluroflan, cortexolone/heparin, CT-2584, cyclophosphamide, cyclosporin A, dexamethasone, diclofenac/hyaluronan, eosinophilic major basic protein, fibronectin peptides, gelatinase inhibitor, glioma-derived angiogenesis inhibitory factor (GD-AIF), GM 1474, gold chloride, gold thiomalate, heparinases, hyaluronan (high and low molecular-weight species), hydrocortisone/beta-cyclodextran, ibuprofen, indomethacin, interferon-alpha, interferon gamma-inducible protein 10, interferon-gamma, IL-1, IL-2, IL-4, IL-12, laminin, levamisole, linomide, LM609, matrix metalloproteinase inhibitor, marimastat (BB-2516), medroxyprogesterone, 6-methylmercaptopurine riboside, metastat (Col-3), methotrexate, minocycline, nitric oxide, octreotide (somatostatin analogue), Paclitaxel, D-penicillamine, pentosan polysulfate, placental proliferin-related protein, placental Rnase inhibitor, plasminogen activator inhibitor (PAIs), platelet factor-4 (PF4), prednisolone, prolactin (16-Kda fragment), proliferin-related protein, prostaglandin synthase inhibitor, protamine, retinoids, Roquinimex (LS-2616. linomide), somatostatin, stromelysin inhibitor, substance P, suramin, SU101, tecogalan sodium (DS-4152), tetrahydrocortisol-sthrombospondins (TSPs), tissue inhibitor of metalloproteinases (TIMP 1, 2, 3), vascular endothelial growth factor inhibitors, vitamin A, Vitaxin and vitreous fluids.
In one embodiment, the combination contains a single composition containing one or more oxidizing agents and/or reducing agents, protein denaturing agents and haptens formulated for injectable delivery or three compositions, one containing an oxidizing agent or reducing agent, another one containing a protein denaturing agent and still another one containing a hapten, where each is in a pharmaceutically acceptable carrier or excipient in an injectable form. Specific therapeutic regimens, pharmaceutical compositions, and kits are also provided.
In a specific embodiment, a combination is provided, which combination comprises: a) a protein denaturing agent; and b) an anti-neoplastic (anti-cancer) agent, such as Ara-C, wherein the protein denaturing agent is not an alcohol or ethanol. In addition, a combination is provided, which combination comprises: a) an oxidizing agent or a reducing agent; b) a protein denaturing agent; and c) an anti-neoplastic (anti-cancer) agent, such as Ara-C.
In another specific embodiment, a combination is provided, which combination comprises: a) an oxidizing agent or a reducing agent; and b) an anti-neoplastic (anti-cancer) agent, such as Ara-C.
In still another specific embodiment, a combination is provided, which combination comprises: a) a hapten; and b) a protein denaturing agent.
In yet another specific embodiment, a combination is provided, which combination comprises: a) a hapten; and b) an oxidizing agent or a reducing agent.
Also provided is a method for treating neoplasm, in particular solid tumors, in a mammal preferably a human, comprising in situ administration of an effective amount of a hapten and coagulation agent(s) or treatment(s) that causes coagulation of the neoplasm, whereby an autologous immune response is generated against the neoplasm and the neoplasm is treated. The autologous immune response generated against the neoplasm can be a humoral and/or a cellular immune response.
Haptens used in the treatment include, but are not limited to, trinitrophenol (TNP), dinitrophenol (DNP), N-iodoacetyl-Nxe2x80x2-(5-sulfonic 1-naphtyl) ethylene diamine (AED), dinitrofluorobenzene(DNFB) and Ovabulin (OVA).
Oxidizing agents used in the methods and combinations, include, but are not limited to, hydrogen peroxide (H2O2), ozone, polyatomic oxygen O7, polyatomic oxygen O8, NaIO4, potassium peroxymonosulfate (oxone), D,L-S-methyllipoic acid methyl ester, tertiary butyl hydroperoxide, menadione, diamide, iodogen, N-bromosuccinimide, omeprazole and N-ethylmaleimide.
Reducing agents used in the combinations and methods include, but are not limited to, hematoxylin, a hypoxic reducing agent such as a nitroimidazole, and nonnitro compound SR 4233.
Protein denaturing agents used in the combinations and treatment include, but are not limited to, an alcohol, guanidine hydrochloride, guanidinium thiocyanate, sodium citrate, 2-mercaptoethanol, sarcosyl, phenol, chloroform and urea. Exemplary alcohols include, but are not limited to, methyl, ethyl, n-propyl, n-butyl, n-pentyl, n-hexyl, n-heptyl, n-octyl, n-decyl, n-dodecyl, n-tetradecyl, n-hexadecyl, n-octadecyl, isopropyl, isobutyl, sec-butyl, tert-butyl, isopentyl, active-amyl, tert-pentyl, cyclopentanol, cyclohexanol, allyl, crotyl, methylvinylmethanol, benzyl, xcex1-phenylethyl, xcex2-phenylethyl, diphenylmethanol, triphenylmethanol, cinnamyl, 1,2-ethanediol, 1,2-propanediol, 1,3-propanediol, glycerol and pentaerythritol alcohol.
Preferably, the combination also includes a facilitating agent and method further comprises administering a facilitating agent that facilitates conjugation between the hapten and a tumor antigen of the neoplasm. The facilitating agents include, but are not limited to, a chelator such as glycyltyrosyl-(N-e-diethylenetri-aminepetaacetic acid)-lysine (GYK-DTPA) or doxorubicin adipic-dihydrazide (ADR-ADH), or a chemical linking agent such as carbodiimide.
Also preferably, the combination also includes an immune response potentiator, and the methods further comprise administering an immune response potentiator to the neoplasm. The immune response potentiators include, but are not limited to, polysaccharides, herb extracts such as Chinese herb extracts, Bacille Calmette-Guerin (BCG), Corynebacterium Parvum, an enzyme such as Vibrio cholera neuraminidase (VCN), Papain, xcex2-Gal and ConA, and a non-virulent virus such as a non-virulent Newcastle virus. Nucleic acids encoding oncogenes or the encoded gene product can also be administered, or be included in the combination of coagulation agents, to enhance the immune response. Exemplary oncogenes include, but are not limited to, abl, erbA, erbB, ets,fes (fps), fgr, fms, fos, hst, int1, int2, jun, hit, B-lym, mas, met, mil (raf), mos, myb, myc, N-myc, neu (ErbB2), ral (mil), Ha-ras, Ki-ras, N-ras, rel, ros, sis, src, ski, trk and yes.
The combinations may also include a coagulation lysing agent and the method further comprises administering such agent to the neoplasm, either separately or as part of the combination. Coagulation lysing agents include, but are not limited to, proteinase K, Glycosyl-phosphatidylinositol-B7 and pancreatin.
These combinations and methods can also be administered concurrently, successively or otherwise in conjunction with chemotherapy, e.g., by further including an anti-neoplasm agent in the combination of coagulation agents or administering a combination provided herein, and, then, preferably within the same day, week or other cycle, administering chemotherapy.
The presently contemplated methods can also be used in conjunction with gene therapy, e.g., by further including a tumor suppressor gene, such as p16, p21, p27, p53, RB, WT-1, DCC, NF-1 and APC, in the combination of coagulation agents. Preferably, the tumor suppressor gene is carried out in a viral vector such as an adenovirus vector, a simian virus vector and a conditionally replicating human immunodeficiency viral vector.
In a preferred embodiment, a particular combination of H2O2 as the oxidizing agent, ethanol as the protein denaturing agent and TNP as the hapten is used in the treatment.
In another preferred embodiment, the oxidizing agent or reducing agent used is from about 0.01% (w/w) to about 35% (w/w), the protein denaturing agent used is from about 1% (w/w) to about 98% (w/w) and the hapten used is from about 1 mg/ml to about 80 mg/ml.
The coagulation can also be achieved by treating the neoplasm with certain physical treatment such as cryotherapy, laser coagulation (ILC), percutaneous microwave coagulation therapy, radio-frequency-induced coagulation necrosis, transpupillary thermotherapy and radiationtherapy.
In a preferred embodiment, the hapten and the coagulation agent(s) are administered to the neoplasm via injection.
In a preferred embodiment, the hapten and the coagulation agent(s) are administered to the neoplasm in combination with a surgical procedure.
Further provided is a method for treating neoplasm, in particular solid tumors, in a mammal preferably a human, comprising in situ administration of an effective amount of an anti-neoplastic (anti-cancer) agent, such as Ara-C, and coagulation agent(s) or treatment(s) that causes coagulation of the neoplasm, whereby the neoplasm is treated. Preferably, the coagulation agent(s) is a protein denaturing agent that is not an alcohol or ethanol. Also preferably, the coagulation agent(s) is a combination of a protein denaturing agent and an oxidizing agent or a reducing agent.
In another specific embodiment, a method is provided for treating neoplasm, in particular solid tumors, in a mammal preferably a human, which method comprises in situ administration of an effective amount of an anti-neoplastic (anti-cancer) agent, such as Ara-C, and an oxidizing agent or a reducing agent that causes coagulation of the neoplasm, whereby the neoplasm is treated.
In still another specific embodiment, a method is provided for treating neoplasm, in particular solid tumors, in a mammal preferably a human, which method comprises in situ administration of an effective amount of a hapten and a protein denaturing agent, whereby an autologous immune response is generated against the neoplasm and the neoplasm is treated.
In yet another specific embodiment, a method is provided for treating neoplasm, in particular solid tumors, in a mammal preferably a human, which method comprises in situ administration of an effective amount of a hapten and an oxidizing agent or a reducing agent, whereby an autologous immune response is generated against the neoplasm and the neoplasm is treated.
Particular compositions of and combinations are described in the sections and subsections which follow.